Provider Demographics
NPI:1548740301
Name:REILLY, AMANDA PAIGE
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:PAIGE
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-3742
Mailing Address - Country:US
Mailing Address - Phone:508-361-2091
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD STE 24
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3109
Practice Address - Country:US
Practice Address - Phone:617-847-1926
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAX101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health